MEC PLAN ENROLLMENT PORTAL
Spillers Works
MEC PLAN INFORMATION
DENTAL INSURANCE INFORMATION
VISION INSURANCE INFORMATION
Spillers Works Enrollment Portal
Plan Information
MEC Plan Selection
*
Ultra MEC
Ultimate MEC
Waiving Medical Coverage
Dental
*
Enrolling
Waiving
Vision
*
Enrolling
Waiving
Ultra MEC
Single
Single + Spouse
Single + Child(ren)
Family
Ultimate MEC
Single
Single + Spouse
Single + Child(ren)
Family
Dental
Single
Single + Spouse
Single + Child(ren)
Family
Vision
Single
Single + Spouse
Single + Child(ren)
Family
Effective Date
*
Plan will start on the first of the month selected. For example, if you choose April, your coverage will begin on 4/1.
January
February
March
April
May
June
July
August
September
October
November
December
Employee Information
Name
*
First
Last
Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Social Security Number
*
Date of Birth
*
MM slash DD slash YYYY
Gender
*
Male
Female
Email
*
Coverage Selections
I would like coverage for:
Select All
MEC Plan
Dental
Vision
Dependent 1 Information
Coverage Selections
I would like to enroll this dependent in the following coverage:
Select All
MEC Plan
Dental
Vision
Name
*
First
Last
Social Security Number
*
Date of Birth
*
MM slash DD slash YYYY
Gender
*
Male
Female
Relationship
*
Spouse
Child
Domestic Partner
Step-Child
Add Another Dependent?
Yes
Dependent 2 Information
Coverage Selections
I would like to enroll this dependent in the following coverage:
Select All
MEC Plan
Dental
Vision
Name
*
First
Last
Social Security Number
*
Date of Birth
*
MM slash DD slash YYYY
Gender
*
Male
Female
Relationship
*
Spouse
Child
Domestic Partner
Step-Child
Add Another Dependent?
Yes
Dependent 3 Information
Coverage Selections
I would like to enroll this dependent in the following coverage:
Select All
MEC Plan
Dental
Vision
Name
*
First
Last
Social Security Number
*
Date of Birth
*
MM slash DD slash YYYY
Gender
*
Male
Female
Relationship
*
Spouse
Child
Domestic Partner
Step-Child
Add Another Dependent?
*
Yes
No
Dependent 4 Information
Coverage Selections
I would like to enroll this dependent in the following coverage:
Select All
MEC Plan
Dental
Vision
Name
*
First
Last
Social Security Number
*
Date of Birth
*
MM slash DD slash YYYY
Gender
*
Male
Female
Relationship
*
Spouse
Child
Domestic Partner
Step-Child
Add Another Dependent?
*
Yes
No
Dependent 5 Information
Coverage Selections
I would like to enroll this dependent in the following coverage:
Select All
MEC Plan
Dental
Vision
Name
*
First
Last
Social Security Number
*
Date of Birth
*
MM slash DD slash YYYY
Gender
*
Male
Female
Relationship
*
Spouse
Child
Domestic Partner
Step-Child
